General practitioners’ decision-making process to prescribe pain medicines for low back pain: a qualitative study

Background Pain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines. Objectives The aim of this study was to investigate what influences GPs’ decision to prescribe pain medicines for LBP. Design Qualitative study with in-depth interviews. Setting Australian primary care. Participants We interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes. Data analysis We summarised GP’s choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP’s decision-making. Results GPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient’s pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process. Conclusions We identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.

The methods part regarding the recruitment of participants should contain more information regarding how the GPs were recruited.As also the authors recognized, there could be a bias due to the fact that most of GPs have long experience in the practice and so young GP are not properly represented.So how this happened?Could not have been possible to involve younger GP?Is there a selection bias or other factors influenced that?Moreover, should also be mentioned in the limitation that 25 is a small sample size.
Why GPs with at least 5 patients in the last 12 months were considered?There is a rational for the number 5? Participant characteristics reported in Table 2 should be better described.For instance how Remoteness: Metropolitan/Rural was defined?how much is the range (minimum -maximum) for age, years of experience, workload?In the caption of Table 2 should be also reported that n=25 so that the Table could stand alone.In Table 3 please report also % and not only counts.In Table 3 is reported that in Vignette 3 for one GP was not possible to record the interview for technical issues.The authors should report this in the methods part and better explain what's happened and why was not possible to record it again.
In the discussion is not clear what are the novelties of this study and what this study in particular add to the literature, as main of the themes are already known in the literature and as the vignettes are also used in other studies.It could be interesting to discuss if prescriptions to real patients would differ from prescriptions using the vignettes.

Other minor comments:
-Abstract line 29 -please correct "describe" with "described".Line 41. Please check the sentence -I think "in" should be removed.line 8 introduction I think that "or" should be deleted.Please check/rephrase the sentence.

REVIEWER
Ivers, Rowena University of Wollongong REVIEW RETURNED 28-May-2023

GENERAL COMMENTS
Dear authors, Thank you for this insight into general practitioner views on prescribing for lower back pain.The sample size is adequate for analysis for a qualitative study, and the authors have noted that men were overrepresented, and that rural GPs were underrepresented.
The vignettes are realistic -in that they have tried other therapies prior to attending the GP.-these are all common scenarios.Description of the themes emerging was executed well.
In the quotes, I can see no mention of heat packs, or referral to physical therapies -if these are not mentioned at all it would be worth mentioning specifically that they were not mentioned.Did any specifically mention keeping active/ moving?If referral to rheumatologist, radiologist for steroid injection and neurosurgeon not mentioned also need to specifically note this (these patients would not necessarily require this).Referral to psychology is written into one of the vignettes (1) and physio into 3.There is one quote where the GP mentioned organising care for elderly mother.
Although the focus is on medications these are all important aspects of therapy.While GPs did not mention guidelines for treatment of back pain, most GPs would most likely have undertaken training with NPS on use of opioids and treatment of neuropathic pain -did any mention this?If so, this needs to be mentioned as was a large national program.NPS guidelines on lower back pain in primary care were released in 2011 but new framework was only released late in 2022 so GPs would not have seen this at the time of the study.Many of these GPs prescribed benzodiazepines -did any participants prescribe melatonin or other less addictive medications for insomnia?If so, this needs to be mentioned -also mention if they did (or did not ) mention advice on sleep hygiene.In terms of prescribing and Subtheme 1, did any participants mention opiate contracts, practice policies or use of real time prescription monitoring (which at that time would have commenced in Vic and maybe in Qld but perhaps not yet in NSW).Did any mention receiving notification regarding their opiate prescribing practices from the Commonwealth government as this program would have occurred prior to these interviews being undertaken.I subtheme 2 -did any mention any specific side effects, such as constipation, sedation (and need for care with driving), addiction or other side effects -If not, need to also mention this.Subtheme -stigma about using antidepressants -the mention of suggesting a mental health diagnosis is raised -did any GPs mention other flowon effects such as effect on the person's life insurance (increases cost of insurance if existing mental health condition).Did any GPs mention risk to themselves or that there is a risk of verbal abuse or risk of physical harm with some clients if medications not prescribed (not a major point but definitely occurs).
In particular, the paragraph regarding using scans to guide treatment is relevant and discussed valid on this point.The paper would have benefited from a general practitioner input, to interpret the findings so as to understand the context of general practice.Best practice in research involving primary care is to include practitioners on the research team.
The manuscript is well written and clear.It reports interesting results even if most of them are not new and known in the literature.
Response to reviewer: Thank you for your positive assessment of our manuscript.

2.
The methods part regarding the recruitment of participants should contain more information regarding how the GPs were recruited.Response to reviewer: We have added more information about recruitmentsee below.GPs were recruited via a market research company (TKW Research Group, Australia) with a large database of healthcare professionals across Australia and New Zealand.Health professionals opt into this database and therefore have already indicated a willingness to participate in research.None of the participants had a prior relationship with the study investigators.The company sent out emails to GPs in their database and scheduled interviews with those who expressed interest in the study.

3.
As also the authors recognized, there could be a bias due to the fact that most of GPs have long experience in the practice and so young GP are not properly represented.So how this happened?Could not have been possible to involve younger GP?Is there a selection bias or other factors influenced that?Response to reviewer: We agree with the reviewer that this is a limitation of our study which we have acknowledged in the discussion.Unfortunately, only a small number of younger GPs were interested in being interviewed or our study we could not recruit more GPs due to budget constraints.

4.
Moreover, should also be mentioned in the limitation that 25 is a small sample size.Response to reviewer: As highlighted by reviewer 2, we believe our sample size is adequate for the purposes of the study.It is typically accepted that saturation can be achieved with fewer than 25 participants in qualitative studiesfor example, 9-17 participants as shown by a recent high-quality review of qualitative studies.1 We achieved saturation with the included sample size.This information has been added to the manuscript: Codes, sub-themes, and themes were reviewed by us, and changes were made as stronger patterns linking codes to themes emerged from the data.Both researchers have a background in physiotherapy and have published on the quality use of pain medicines.17-19Data saturation was reached (i.e.no new themes emerged).
Reference: 1. Hennink M, Kaiser BN.Sample sizes for saturation in qualitative research: A systematic review of empirical tests.Soc Sci Med.2022 Jan;292:114523.

5.
Why GPs with at least 5 patients in the last 12 months were considered?There is a rational for the number 5?
Response to reviewer: Our intention was to avoid recruiting GPs with no experience in managing low back painwhich arguably is next to impossible given the prevalence of back pain consultations in Australian general practice and the prevalence of the conditionand five is an arbitrary number.We have made that clearer in the manuscript.We recruited 25 GPs registered to practise in Australia who reported having provided care for at least five patients with LBP with or without sciatica in the last 12 months.Four or less is what our team thought would be representative of little to no experience in managing LBP.We defined sciatica as a back problem with radiating pain below the knee with or without neurological symptoms (e.g.reduced muscle strength, sensation, or reflexes).126.
Participant characteristics reported in Table 2 should be better described.For instance how Remoteness: Metropolitan/Rural was defined?how much is the range (minimum -maximum) for age, years of experience, workload?In the caption of Table 2 should be also reported that n=25 so that the Table could stand alone.
Response to reviewer: Metropolitan areas are defined following the recommendations of the Australian Statistical Geography Standard and encompass GPs working in Greater Capital City Statistical Areas.We have added that information to Table 2.
We have also added range (min-max) of experience and workload.

7.
In Table 3 please report also % and not only counts.Response to reviewer: We have provided counts in the table, in brackets.We have added "%" to each value to improve clarity.

8.
In Table 3 is reported that in Vignette 3 for one GP it was not possible to record the interview for technical issues.The authors should report this in the methods part and better explain what's happened and why was not possible to record it again.Response to reviewer: We provided more information in the first paragraph of the results.It reads as follows: We interviewed 25 GPs from April to June, 2022.Most were males (64%) practising in metropolitan areas across six states of Australia.Their mean (SD) age was 53.4 (9.1), and they had a mean of 24.5 (9.3) years of practice as GPs.All but three worked full-time in private practices (Table 2).The recoding of one interview was mistakenly interrupted just before vignette #3 started and therefore there are only data from 24 GPs for that vignette.

9.
In the discussion is not clear what are the novelties of this study and what this study in particular add to the literature, as main of the themes are already known in the literature and as the vignettes are also used in other studies.Response to reviewers: Our findings align with some of the existing evidence around decision making in general practice; however, we believe that they provide valuable insights that could inform future work in the field of low back pain, where similar research was lacking prior to our study.One novel finding of our study, and one that we discussed in the manuscript, is the fact that many GPs decided which pharmacological treatment to prescribed based on a presumed pathoanatomical diagnosis for LBP.Our findings also help us understand what motivates GPs to prescribe certain medicines, which can inform the design of future interventions aimed at altering prescribing behaviours to better match new evidence and clinical practice guidelines.We would also like to clarify that the vignettes used in our study were created by our study team, as described in the methods, for this study specifically.They have not been used before in other studies.

10.
It could be interesting to discuss if prescriptions to real patients would differ from prescriptions using the vignettes.
Response to reviewers: We agree with the reviewer and have added the following to the discussion: However, the decision-making processes described in our study were anchored to the information provided in the vignettes and may not necessarily be generalisable to all LBP cases or truly reflect objective prescription data.35For example, while our study did show that GPs would most commonly prescribe or conditionally prescribe opioids for an acute exacerbation of chronic LBP (vignette 1) or subacute sciatica (vignette 2), which agrees with Australian data on prescription medicines for LBP,3 our finding that GPs would more commonly prescribe antidepressants for the patient with chronic LBP in vignette 3 differs from existing data.It is unknown whether this difference may be due to the characteristics of the vignette and reflective of practice for patients with the characteristics described in that vignette.Our sample was composed mostly of very experienced GPs practising in metropolitan areas.Views of more experienced GPs may differ from those in earlier stages of their careers.
Line 41. Please check the sentence -I think "in" should be removed.
Response to reviewers: Corrected, thank you.
13. line 8 introduction I think that "or" should be deleted.Please check/rephrase the sentence Response to reviewers: We have rephrased the sentence.It now reads as follows: Australian data shows that 2 in every 3 patients who seek primary care are prescribed or recommended at least one pain medicine.2REVIEWER 2 14.Thank you for this insight into general practitioner views on prescribing for lower back pain.The sample size is adequate for analysis for a qualitative study, and the authors have noted that men were overrepresented, and that rural GPs were underrepresented.Response to reviewer: Thank you for your positive assessment of our manuscript.

15.
The vignettes are realistic -in that they have tried other therapies prior to attending the GP.these are all common scenarios.
Response to reviewer: Thank you.We piloted the vignettes with clinicians experienced in managing back pain to ensure that they were representative of common cases seen in daily practice.

16.
Description of the themes emerging was executed well.
Response to reviewer: Thank you.

17.
In the quotes, I can see no mention of heat packs, or referral to physical therapies -if these are not mentioned at all it would be worth mentioning specifically that they were not mentioned.Response to reviewer: heat packs were not mentioned, but a small number of GPs did mention referral to physical therapies.We did not include that information as it is outside the scope of the manuscript, which focused on prescribing of medicines.

18.
Did any specifically mention keeping active/ moving?If referral to rheumatologist, radiologist for steroid injection and neurosurgeon not mentioned also need to specifically note this (these patients would not necessarily require this).